Nutrition in Clinical Practice最新文献

Background: Blenderized tube feeding (BTF) use has increased in patient populations requiring enteral nutrition support, and healthcare providers need to be well-informed on the nuances of BTF-including administration. Patients and caregivers frequently prefer right-angle extension sets but are encouraged to use straight sets to avoid a potential clog at the right angle. The purpose of this study was to compare clog occurrences in straight and right-angle extension tubes between standard commercial formula (SCF) and all viscosity levels of BTF. The accuracy of formula volume delivered was also explored.

Methods: A home-prepared and a commercial product were manipulated such that all four viscosity levels were achieved and delivered by pump and syringe through right-angle and straight extension sets in mock tube feedings. A comparison SCF was also delivered via pump without adjusting the viscosity. All 1-h feedings were observed for any clogs at the right-angle or in the straight extension set.

Results: No clogs were observed at any viscosity level in pump delivery for right-angle or straight extension sets. One clog was observed in a single-observation syringe feeding. The volume delivered was more consistent at all viscosity levels through the right-angle sets, compared with straight set tubes delivering the 200-ml volume in 1 h.

Conclusion: Patient preference for right-angle extension sets may be honored for BTF delivered via new-generation feeding pumps.

Background: The effectiveness of thiamin supplementation in mitigating renal injury and mortality outcomes in patients with septic shock remains uncertain. This systematic review and meta-analysis aimed to determine the efficacy of thiamin in patients with septic shock.

Materials and methods: A systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of septic shock with thiamin, compared with placebo or blank, were reviewed. Studies were pooled to risk ratios (RRs) and weighted mean differences, with 95% confidence intervals (CIs). Six RCTs (enrolling 438 patients) met the inclusion criteria.

Results: Thiamin showed significant effects on in-hospital mortality (RR 0.80, 95% CI 0.65-0.99; P = 0.04) and renal replacement therapy (RR 0.48, 95% CI 0.31-0.74; P = 0.0009).

Conclusion: Thiamin was associated with a reduction in in-hospital mortality and the use of renal replacement therapy in patients with septic shock. Thiamin should be considered for patients with septic shock.

Background: Skeletal muscle is critical for functional status, quality of life, and treatment tolerance in pediatric patients with cancer. Traditional assessments of muscle mass involve radiation and are often unsuitable for frequent monitoring. Ultrasound (US) is noninvasive and radiation-free; however, its reliability in pediatric patients with cancer, who experience rapid changes in body composition, is not well established. This study aimed to determine the interrater reliability of US for measuring key muscle parameters.

Methods: A novice and an expert sonographer blindly measured muscle thickness (mT), cross-sectional area (CSA), and echo intensity (EI) for the quadriceps femoris (QF) and tibialis anterior (TA) muscles in an oncology group and a healthy group. Interclass correlation coefficients were calculated to assess interrater reliability.

Results: A total of 27 participants were included (n = 14 oncology and n = 13 healthy). All quadriceps measures had good reliability, with QF mT = 0.895 (95% CI, 0.77-0.952), rectus femoris (RF) mT = 0.881 (95% CI, 0.74-0.946), CSA = 0.801 (95% CI, 0.563-0.909), and EI = 0.839 (95% CI, 0.647-0.927). All TA measures had excellent reliability: mT = 0.968 (95% CI, 0.929-0.985), CSA = 0.925 (95% CI, 0.835-0.966), and EI = 0.909 (95% CI, 0.801-0.959). The oncology group's reliability remained high. Key results included RF mT = 0.906 (95% CI, 0.706-0.970), QF mT = 0.887 (95% CI, 0.646-0.964), TA mT = 0.972 (95% CI, 0.912-0.991), CSA = 0.947 (95% CI, 0.836-0.983), and EI = 0.943 (95% CI, 0.822-0.982).

Conclusion: Point-of-care US is a reliable method to measure muscle in pediatric oncology patients. Moreover, novice sonographers can be trained to perform these measurements reliably.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused significant morbidity and mortality. Further study of modifiable factors influencing COVID-19 severity and outcomes continues to be necessary. Serum zinc levels may play a role in modulating COVID-19 virus replication and consequently influence clinical outcomes.

Methods: This was a prospective observational study of adult patients hospitalized with COVID-19 assessing the relationship between serum zinc levels and clinical outcomes. Serum zinc levels were measured within 7 days of admission. The primary outcome was the need for intubation at any time during inpatient stay. Secondary outcomes included hospital disposition and incidence of shock and acute kidney injury.

Results: Serum zinc levels could be obtained for 99 patients with COVID-19. The 25 requiring intubation during hospitalization had a statistically significantly lower median (IQR) zinc concentration (51.6 µg/dl [46.3-62.3 µg/dl]) than those who did not (64.4 µg/dl [55.2-76.0 µg/dl]; P < 0.01). Patients requiring more respiratory support on hospital day 1, having acute kidney injury on hospital day 8, or requiring pressors on hospital days 1 or 8 also had significantly lower zinc levels. In multivariable analysis including other clinical factors known to influence outcomes in COVID-19 disease, serum zinc level remained an independent predictor of the need for intubation (odds ratio 0.941, 95% CI 0.885-0.999; P = 0.048).

Conclusion: In multivariable analysis, lower serum zinc level was an independent predictor of inpatient intubation in COVID-19, but further investigation of zinc supplementation to prevent or reduce severity in COVID-19 infection is warranted before routine clinical use.

Background: Short bowel syndrome (SBS) is a chronic condition requiring parenteral nutrition (PN) support and multidisciplinary management. However, disparities in access to care and standardized treatment pathways, in addition to economic burden, remain considerable for patients. Understanding healthcare resource utilization (HCRU) and treatment patterns, especially in relation to patient-reported outcomes (PROs), is critical for improving care.

Methods: A cross-sectional, multiphase study was conducted in 2023. This analysis focuses on phase 3, using a deidentified database that integrated claims and PROs from 68 patients in phase 2. Twenty-three patients were included in the analytic cohort after applying additional criteria. Descriptive statistics summarized patient demographics, HCRU, and treatment patterns for the overall cohort and stratified by median SBS-quality of life (QoL) score.

Results: The median age at SBS diagnosis was 35 years, and 91% of patients were female. Patients saw a median of 35 different healthcare providers and underwent approximately five procedures before diagnosis. In the 6 months after diagnosis, 39% had been hospitalized, and 26% had emergency room (ER) visits. Healthcare costs increased after diagnosis, with long-term PN use accounting for 34% of total costs. Patients with worse QoL had a higher number of ER visits than patients with better QoL. Patients who self-reported being treated by SBS specialists had lower healthcare costs than patients who did not receive specialized care.

Conclusion: SBS is associated with high HCRU and costs, particularly for patients with poor QoL. Multidisciplinary care, especially from SBS specialists, may help reduce healthcare costs and improve patient outcomes.

Survivors of critical illness frequently do not achieve recommended nutrition targets because of multiple barriers. Consequently, malnutrition is prevalent during hospitalization, yet posthospital discharge nutrition interventions are often missing, leaving a gap during a crucial recovery phase. This scoping review aims to explore barriers to nutrition adequacy, consequences of inadequate nutrition, and interventions for adult survivors of critical illness following hospital discharge. Using Joanna Briggs Institute methodology in conjunction with the PRISMA-ScR checklist, searches were conducted in MEDLINE, Embase, CINAHL, Web of Science, and Cochrane databases (2010-2024) for studies on adult intensive care unit (ICU) survivors posthospital discharge, reporting nutrition barriers, consequences, and/or nutrition interventions. Factors identified from the data are analyzed and presented using a conceptual framework derived from the Biopsychosocial model and the Social Ecological Model. Forty-three studies (mostly observational) were included encompassing 32,165 participants. Commonly reported barriers included (% of studies) appetite loss (40%), dysphagia (26%), and psychological distress (40%), contributing to inadequate dietary intake (19%), malnutrition (42%), and weight loss (56%) persisting up to 12 months. Body composition changes, observed in 21% of studies, demonstrated increased fat mass, whereas lean mass was maintained or lost. Despite high nutrition risk, only 37% reported nutrition input. Nutrition interventions improved nutrition, physical, and psychological outcomes. This review emphasizes the complexity of nutrition recovery faced by ICU survivors, highlighting significant gaps in nutrition care following hospital discharge. Understanding nutrition challenges from survivors' perspective is essential before evaluating specific nutrition interventions addressing the diverse nutrition needs of individuals recovering from critical illness.

Background: Patients receiving home parenteral nutrition (HPN) face complex challenges and increasingly seek support online, including generative artificial intelligence (AI) platforms like ChatGPT. This survey study compared ChatGPT with clinician responses to common HPN-related questions.

Methods: Responses to 20 HPN-related questions spanning five content themes were generated by ChatGPT and provided by HPN expert clinicians. In a blinded online survey, practicing clinicians (study participants) rated each response on a five-point scale (1 = excellent; 5 = very poor) for accuracy, appropriateness, and empathy and selected their overall preferred response.

Results: Among 23 participants (73.9% registered dietitians; mean HPN experience: 14.0 years), ChatGPT's responses were rated more favorably for accuracy (median [IQR] = 1.80 [0.79] vs 2.15 [0.62], P = 0.003), appropriateness (1.80 [0.70] vs 2.15 [0.53], P = 0.013), and empathy (1.95 [0.66] vs 2.25 [0.65], P = 0.007). Participants preferred ChatGPT responses in 48.5% of cases, clinician responses in 33.9%, and had no clear preference in 17.6%. ChatGPT outperformed clinicians across content themes for "best practices, care, and safety of HPN use/infection risk" and scored more favorably for empathy in "symptoms" and for accuracy and appropriateness in "lifestyle stressors." Clinicians scored more favorably for appropriateness in "biochemical test concerns."

Conclusion: ChatGPT may support HPN care and patient education, particularly for broad medical and lifestyle topics. However, complex clinical issues require medical expertise. Further research is needed to guide the safe integration of AI into clinical practice and patient care.

Background: Clinical nutrition (CN) is becoming increasingly complex because of the rising prevalence of chronic illness, cancer, and malnutrition-related conditions such as short bowel syndrome and refeeding syndrome. Despite its clinical significance, nutrition education among US physicians remains limited. Simultaneously, large language model (LLM)-based artificial intelligence assistants (AIAs) have emerged as tools to support complex clinical decision-making but remain largely untested in CN.

Methods: This retrospective study evaluated four LLM-based AIAs-ChatGPT (OpenAI), OpenEvidence (OpenEvidence Inc), Gemini (Google, Google DeepMind), and Copilot (Microsoft Corporation)-using five complex CN cases from our nutrition support service. Each AIA was queried with patient-specific CN questions. Responses were blinded and reviewed by five physician CN experts using an eight-item assessment tool evaluating clarity, relevance, evidence, and clinical utility.

Results: All AIAs produced clinically appropriate responses, with Gemini scoring highest in relevance (4.04) and clarity (4.16). Overall satisfaction scores ranged from 3.08 (Copilot) to 3.84 (Gemini). Citation quality and originality of insights varied and were generally limited, and no consistent differences in performance were observed across the five cases among the four AIAs.

Conclusion: LLM-based AIAs can reliably replicate expert reasoning in CN. Although not yet a source of novel clinical insights, the true potential of this approach may lie in its application among physicians without specialized expertise in CN, helping to bridge existing knowledge gaps in nutrition care. Presenting full clinical cases, as shown in this study, could support AIA-enabled e-consultation in the future, thereby addressing gaps in CN education.

Background: Although previous experimental studies showed that metabolic acidosis promoted muscle catabolism and impaired protein synthesis, few epidemiological studies reported an independent association between serum bicarbonate levels and muscle atrophy in patients with chronic kidney disease (CKD). We examined the association between serum bicarbonate levels and low mid-upper arm circumference (MUAC), a surrogate marker of low muscle mass, in older adults with non-dialysis-dependent CKD.

Methods: A total of 174 patients aged ≥65 years with an estimated glomerular filtration rate <60 ml/min/1.73 m² (33.9% women) were eligible. We cross-sectionally examined the association between serum bicarbonate levels and MUAC using multiple linear regression, adjusting for potential confounders selected by a directed acyclic graph of our causal model. The association between serum bicarbonate and low MUAC was examined by multiple Poisson regression with robust variance. We used two cutoffs to define low serum bicarbonate: serum bicarbonate levels <24 and <22 mmol/L.

Results: Serum bicarbonate levels were positively associated with MUAC (coefficient = 0.158, 95% CI = 0.026-0.289; P = 0.019). Serum bicarbonate levels <24 mmol/L were associated with a higher prevalence of low MUAC (prevalence ratio = 3.50, 95% CI = 1.61-7.61; P = 0.002), whereas the association was attenuated for serum bicarbonate levels <22 mmol/L. Restricted cubic spline analyses suggested a nonlinear association between serum bicarbonate levels and low MUAC.

Conclusion: We found an independent association between serum bicarbonate levels <24 mmol/L and low MUAC, calling for further prospective studies to elucidate the target serum bicarbonate level that would help retard muscle atrophy.

Background: Persons living with amyotrophic lateral sclerosis (PALS) are at high risk for malnutrition because of disease-related factors such as dysphagia, self-feeding difficulty, and hypermetabolism. Nutrition interventions, including enteral nutrition (EN) initiation after gastrostomy tube (G-tube) placement, are integral to care but can introduce challenges, such as refeeding syndrome. This qualitative analysis explores how registered dietitians (RDs) at US-based outpatient amyotrophic lateral sclerosis (ALS) clinics assess malnutrition, facilitate discussions around G-tube placement, and mitigate refeeding syndrome risk.

Methods: Six focus groups were conducted with 22 RDs from US ALS clinics. Audio files were transcribed verbatim, and data analyzed by deductive thematic analysis.

Results: RDs reported widespread use of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators for diagnosing malnutrition, with some using the Global Leadership Initiative on Malnutrition criteria. However, RDs described limitations in using these tools for PALS, particularly in differentiating disease-related from malnutrition-related muscle loss. When discussing G-tube placement, RDs described themselves as key informants in multidisciplinary teams, with timing of counseling typically based on symptoms and clinical progression. For refeeding syndrome, most clinics lacked formal protocols, although RDs used preventative practices, including slow initiation and advancement of EN and proactive communication with the care team.

Conclusions: ALS RDs play a critical and multifaceted role in managing nutrition-related ALS care. There is a need for ALS-specific malnutrition criteria and standard protocols to manage refeeding syndrome in the outpatient setting. RDs' involvement in G-tube discussions underscores their role in supporting patients in medical decision-making.